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Perla, Annette E. Scott McClelland, Annette L. Sociodemographic and behavioral characteristics of Peruvian female sex workers FSWs were analyzed. The association between genital tract infections GTIs and risk factors by multivariate analysis was evaluated. Reported condom use with clients was nearly universal Continued health outreach programs and integrating family planning and reproductive health services into existing STI clinic services are recommended.

To address the perceived public health threat from the human immunodeficiency virus HIV epidemic in Peru, studies were conducted in the s to characterize the sexual practices and prevalence of genital tract infections GTIs—sexually transmitted infections and bacterial Women looking for sex free Las PerLas and HIV among female sex workers FSWs and their clients. These findings also concluded, however, that while the HIV prevalence among FSWs in Peru was higher than that of the general population, the estimates for this at-risk population were relatively low for a concentrated epidemic setting and the rate of ongoing transmission was considered slow [ 24 ].

Consequently the focus on prevention programs targeting FSWs has somewhat diminished. It has been the norm to rely on a convenience sample of women who attend free government STI clinics although it is known that a segment of the FSW population does not access or underutilizes these services [ 56 ].

Concern regarding a sudden and hidden spread of HIV and STIs among FSWs is periodically raised due to on-going bridge potential from the sexual networks of bisexual men [ 7 — 9 ]. For over years female sex work in Peru was tolerated and controlled with required worker registration, mandatory periodic clinical exams of FSWs to maintain a valid healthand an informal recognition of sex work venues.

In FSWs were no longer required to register, and in periodic exams became voluntary. The term clandestine originally referred to women who did not register, but currently refers to women who never or seldom use free public health STI services for recommended, periodic health checks and who frequent commercial sex venues that are not recognized and not commonly accessed by government STI prevention outreach programs.

The purpose of this study was to provide a profile of GTI prevalence, sexual health status, and health-seeking behaviors amongst clandestine FSWs in Peru. For this descriptive, cross-sectional study a convenience sample of clandestine FSWs based in Lima, Peru was recruited in and Participants self-identified as FSW and were initially approached at their clandestine sex workplaces by peer educators who served as study recruiters.

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To optimize inclusion we used two primary recruitment strategies. First, over a nine-month period, weekly open-house sessions were hosted at the clinic site for members of the clandestine sex work community. Four trained peer educators made several weekly visits to network with sex workers and venue gatekeepers.

This resulted in the identification of 75 clandestine sex work venues, including streets or parks and other commercial sex venues not formally recognized by the Peruvian government. Secondly, women who attended open houses were briefed on the study, encouraged to participate and asked to refer their colleagues who might be eligible for the study. This strategy, considered a form of snowball sampling, is frequently used to recruit members of hard-to-reach populations [ 1213 ].

Sample selection criteria were tailored to be consistent with the national definition of a sex worker and intentionally sought to include a high-risk subpopulation of FSW. Women who were currently pregnant were excluded from the analysis. Written informed consent was obtained from all participants after the study was explained, and eligibility was confirmed based on study inclusion and exclusion criteria.

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A Women looking for sex free Las PerLas female counselor administered the behavioral health questionnaire to participants prior to the medical exam. The behavioral survey was developed based on questionnaires ly used in international, regional, and local studies. A female gynecologist performed the pelvic examinations and specimen collections.

Vaginal fluid from the upper lateral wall of the vagina was collected with a cotton swab and prepared for wet mount and Gram stain evaluation. Gram stain was used to diagnose bacterial vaginosis BV on basis of the Nugent score criteria [ 14 ]. Trichomonas vaginalis was detected using the wet mount examination and the In-Pouch TV culture system Biomed. Anal specimens were not collected. Finally, a 10 cc venous blood sample was collected to conduct serological tests for Treponema pallidum syphilis using rapid plasma reagin RPR—nosticon II Kit; Biomerieux and T.

A follow-up visit was scheduled after two weeks to provide the of laboratory tests, as well as HIV and STI post-test counseling. All participants received STI educational materials and condoms. Statistical analyses were conducted using Stata IC 10 [ 15 ]. We used descriptive statistics to assess the range, mean, and standard deviation of sociodemographic, behavioral, and clinical exam variables.

Descriptive statistical methods were used to explore candidate risk factors for BV, T. Candidate risk factors and potential confounders were assessed individually in relationship to all GTI outcomes with a sample size of 20 or more. In general covariates included age, level of education, marital status, of dependents, estimated income from sex work, years as sex worker, work venue, of clients in the past week, condom use and problems with condom use with 3 most recent sex partners, use of hormonal contraceptives, use of lubricants, anal sex, and months since last clinic visit.

Factors associated with a GTI outcome with using bivariate Poisson and logistic regression were considered for multivariate regression modeling. Multivariate modeling was carried out using either logistic regression to estimate odds ratios ORs or Poisson regression to estimate prevalence rate ratios PRRs. Overall of female study participants recruited from 75 work locations met all inclusion criteria and were willing to be tested for all GTIs.

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The mean age at first sexual intercourse was The age for the first sex work transaction ranged from 12 to 48; the mean age was The mean duration acknowledged sex work was 4. Five women reported partners or more in the past work week. Sex venues traditionally sanctioned by the Peruvian government, such as house of appointments and brothels, were less common among this population.

A smaller percentage of FSWs identified massage parlors as their work venue and a few reported establishing contacts with clients by telephone and internet. Ninety-three women reported not using a contraceptive method; among these, 5 women reported not using contraception because they did not menstruate or have a uterus.

The average of pregnancies was 2. Clinical and laboratory examination indicated an HIV seroprevalence of 2. Overall, Forty-five percent were diagnosed with BV defined as a Nugent score between 7 and The 5 women diagnosed with T. Nine percent were seropositive for syphilis and 9. Study participants were asked to describe symptoms or s they recognized as a GTI among women and men.

We aggregated the data to identify differences in condom use by type of sexual partner. FSWs reported using condoms during nearly all sex acts Moderate-to-high levels of collinearity between several of the correlates seen in bivariate analyses, for example, age and s of years in sex work, likely precluded our ability to assess the independent effects of these factors in our modest sized sample. We did not detect an association between syphilis seropositivity and any of the measures of condom use captured under this study.

This may be because none of the 20 seropositive women had serological evidence consistent with a recent infection. There are several limitations to our study; principally that interpretation is based on cross-sectional data which precludes evaluation of the temporal relationship between risk factors and GTIs. The statistical power to understand relationships with some correlates, particularly for HSV-2, was limited as the sample size was small.

Participants were asked sensitive questions regarding their behaviors and thus their responses may have been affected by recall and social desirability biases. Because we followed international standards for framing these questions and used rigorously trained interviewers, we believe these effects were minimized. The generalizability of study to other clandestine FSWs is likely limited due to the snowball sampling methods and recruitment efforts which favored the adjacent neighborhoods of Lima Cercado downtown Lima and La Victoria.

Participation bias Women looking for sex free Las PerLas also have occurred if recruitment efforts predominantly captured women with existing conditions or pressing health concerns. Our data revealed that the HIV seroprevalence of 2.

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Our data highlight effective efforts by the Peruvian public health community to stave off widespread HIV transmission in this vulnerable population. This study also documents prevalence rates of concern for other GTIs. Bivariate analyses reported here show increasing risk of infection at older ages.

No association with condom use was detected, consistent with the assessment that condom use is less effective against HSV-2 acquisition compared to other STIs [ 22 ]. Evidently public health interventions were unsuccessful at preventing the steady accumulation of HSV-2 infections among FSWs.

Furthermore, the BV prevalence of In our study women with BV were more likely to be diagnosed with another GTI, and BV diagnosis was independently associated with lack of condom use, associations which are consistent with other studies [ 25 — 29 ]. Our study reports no evidence of recent syphilis, consistent with an interpretation of low frequency of transmission. Our suggest areas where efforts to build knowledge and awareness and to elicit sustained behavior change could further benefit sexual and reproductive health in this marginalized population.

The high percentage of women who reported experiencing vaginal discharge or a genital ulcer in the past year likely does not capture the full range of GTI-related morbidity in this population as familiarity with the range of associated symptoms was low. Moreover, nearly three-quarters of the women did not seek medical care as their first response to vaginal symptoms whereas pharmacies were the preferred source for medical attention suggesting that self-medication and alternatives to specialized GTI services appear to be the preferred recourse.

Stigma, driven by discriminatory treatment and concerns for confidentiality, is a major reason for reluctance to use free STI clinic services [ Women looking for sex free Las PerLas ]. Some in the Peruvian context have worked towards strengthening the capacity for pharmacies to provide information and medication based on syndromic STI case management approaches [ 3233 ]; however the effectiveness of these approaches for FSW populations has not been assessed. These findings highlight the need to address both the potential STI transmission to and the burden of STI among stable partners of FSWs, themselves a potential bridge population to lower risk segments of the general population [ 5 ].

The reproductive health profile of participants revealed an average of 2. Although reported condom use in the context of commercial sex was high, complementary use of contraceptive methods was lacking. Patterns indicate that condoms are perceived principally as STI prevention rather than a family planning method. Thus survey response on condom use as a contraception method may reflect the lack of integration between STI prevention and family planning programs in Peru with respect to these interrelated behavior change objectives.

Abortion in Peru is illegal thus limiting our ability to understand the prevalence of unsafe abortions and their impact on maternal morbidity and mortality [ 35 — 37 ]. studies estimated the Peruvian abortion rate to be one of the highest in Latin America [ 3839 ].

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Given the self-medication behavior through pharmacies as reported in our study and the availability of medications including mifepristone and misoprostol RUit is plausible that medical abortions are becoming more widely used by this population [ 41 ]. This study supports the notion that FSWs are not only a vulnerable population due to GTI risk and their sequelae, but also because of an elevated risk of reproductive health problems.

These risks likely arise from a constellation of disadvantages including limited access to reproductive health information, possible unmet demand for family planning methods and the cumulative effect of seeking to terminate unwanted pregnancies. Public health polices related to FSWs have not changed in the past 10 years, and family planning is currently not included in the protocol of STI clinical exams for FSWs [ 42 ].

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Requesting reproductive health information requires a separate appointment, often at a different clinic. The nearly universal condom use with clients reported in our study of a subpopulation of FSW who were relatively new to commercial sex or did not attend public STI clinics suggests a noteworthy achievement of a proactive approach to STI and particularly HIV prevention in Peru since the s. Nonetheless, the high burden of some STIs, BV, and abortions in this population also indicates that a services-access gap likely persists.

These findings also justify renewed efforts to support outreach services to marginalized FSW populations with integrated behavior change messages that include building awareness of STI symptoms in men and women, promoting availability of free STI services and alternative HIV testing sites, and educating FSWs to differentiate appropriate healthcare-seeking behavior from inadequate self-medication patterns.

Data reported here also highlight the urgent need both to integrate family planning and reproductive health services into existing client-friendly STI clinical services and to stay abreast of innovation in female-controlled methods that expand options to prevent pregnancy and STI, particularly during sex with those intimate or non-commercial partners who are unlikely to use condoms.

First and foremost the authors would like to thank the female sex workers who participated in the Esperanza project, including its community development programs, and who agreed to participate in this study. Additionally, the authors thank the dedicated staff directly involved in serving study participants and the many colleagues who supported this work.

The authors would like to thank Dr. Zoraida E. Ghee and S. Margot Guevara was the Research Coordinator and Dr. Miriam Contreras was the Study Physician. Perla prepared and analyzed the data and led the development of the paper. At the time of the study, A. At the time of the analysis and paper preparation, M. Perla was affiliated with the Department of Epidemiology at the University of Washington.

The opinions expressed are the private ones of the authors and are not to be construed as reflecting the views of the funding agency. Perla et al. This is an open access article distributed under the Creative Commons Attributionwhich permits unrestricted use, distribution, Women looking for sex free Las PerLas reproduction in any medium, provided the original work is properly cited.

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Perla, 1 Annette E. Scott McClelland, 1,4,5 Annette L. Academic Editor: Gregory T.

Women looking for sex free Las PerLas

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Genital Tract Infections, Bacterial Vaginosis, HIV, and Reproductive Health Issues among Lima-Based Clandestine Female Sex Workers